01-최일국

대한응급의학회지제 22 권제 6 호 Volume 22, Number 6, December, 2011 원 저 심전도정보전달체계구축이 ST 분절상승심근경색환자의재관류치료시간단축에미치는효과 단국대학교의과대학응급의학교실, 심장내과학교실 1 최일국 최한주 오성범 강태수 1 Effect of Establishing an ECG Transmission System on Time Required for Patients with ST-segment elevation Myocardial Infarction to Receive Reperfusion Therapy Il Kook Choi, M.D., Han Joo Choi, M.D., Sung Bum Oh, M.D., Tae Soo Kang, M.D. 1 Purpose: Prompt reperfusion therapy by means of primary percutaneous coronary intervention is an effective method for treating patients with ST-segment elevation myocardial infarction (STEMI). According to the ACC/AHA guidelines for these patients, the interval between arrival at the hospital and intracoronary balloon inflation (door-to-balloon time) should be 90 minutes or less. The aim of this study was to evaluate the effect of establishing an ECG transmission system and communication procedure in the emergency department (ED) to minimize door-to-balloon time for STEMI patients. Methods: We established both the out-of hospital and inhospital aspects of the ECG transmission system. Before patient arrival at our ED, we would attempt to receive initial ECGs from the referring hospitals via fax. In ideal cases, ECG findings were immediately reported to interventional cardiologists by the referring primary ED physician. Door-toballoon time segments were analyzed in a retrospective manner. We compared the effectiveness in minimizing reperfusion time between the use of inter-hospital 12-lead ECG transmission before patient arrival, and direct communication between emergency physicians and attending interventional cardiologists. 책임저자 : 최한주충청남도천안시동남구안서동산16-5 단국대학교병원응급의학과 Tel: 041) 550-6840, Fax: 041) 550-7054 E-mail: iqtus@hanmail.net 접수일 : 2011년 8월 24일, 1차교정일 : 2011년 9월 7일게재승인일 : 2011년 9월 23일 591 Results: Of the total 142 STEMI patients who received percutaneous coronary intervention (PCI) during the study period, 112 (78.9%) received PCI within 90 min. The mean door-toballoon time of the 27 patients admitted with a pre-arrival 12- lead ECG transmission was significantly less than the others. Conclusion: Establishing both out-of hospital and in hospital strategies to reduce door-to-balloon time in patients with STEMI, by using pre-arrival ECG transmission and direct communication between emergency physicians and interventional cardiologists, is an effective approach to minimize time to reperfusion. Key Words: Myocardial infarction, Reperfusion, Total quality management Department of Emergency Medicine, Department of Cardiology 1, College of Medicine, Dankook University, Cheonan, Korea 서 급성심근경색은세계적으로성인의가장흔한사망원인중하나이며우리나라에서도전체사망원인의약5% 를차지한다 1,2). ST 분절상승심근경색 (ST-segment elevation myocardial infarction, STEMI) 환자에대한즉각적인재관류요법은폐쇄된관상동맥내의정지된혈류를재개시켜환자를생존하게한다 3). 재관류의방법중경피적관상동맥중재술 (percutaneous coronary intervention, PCI) 은혈전용해제 (thrombolytics) 를이용한재관류에비하여단기사망률의감소와함께재경색 (reinfarction) 이나뇌졸중등의합병증발생을감소시키는것으로보고된다 4-6). 재관류의방법외에도 STEMI 환자의응급실내원이후재관류까지소요되는시간 (door-to-balloon time) 의단축이환자의사망률과이환율을의미있게감소시킨다는것은알려진사실이다 7). 2004년에발표된미국심장협회치료지침 (American College of Cardiology/ American Heart Association (ACC/AHA) guidelines) 은 STEMI 환자의내원이후재관류까지소요되는시간이 론

592 / 대한응급의학회지 : 제 22 권제 6 호 2011 90분이내일것을일차적인치료목표로제시하였으며, 기관에내원한전체 STEMI 환자들중 75% 이상에서이러한치료목표를달성해야할것을권고하였다 1). 대부분의 3차병원들이 STEMI 환자의신속한치료에대한전략을세우고실행에옮기고있으나미국심장협회에서제시한치료목표를달성하기는쉽지않다 8,9). 미국의국가심근경색통계 (national registry of myocardial infarction, NRMI) 자료를분석한보고에따르면, 1999년부터 2002년까지전체 STEMI 환자중 4.2% 만이 90분이내에경피적관상동맥중재술을시행받았고, 내원이후재관류까지소요되는시간의중앙값은 180분이었다 10). 치료지침이제시된 2004년이후의자료를분석한결과에따르면, 경피적관상동맥중재술팀의일근무시간 (regular-hours) 에는대부분의 STEMI 환자에서내원이후재관류까지소요되는시간이 90분이내였으나, 근무외시간 (off-hours) 에는모두 90 분을넘겼다 11). 본연구에서는일개대학병원응급실에내원한 STEMI 환자를대상으로응급의학과소속의료진이직접심장내과전문의와연락하여관상동맥중재술팀을활성화시키는것을핵심전략으로삼고기존의프로토콜을더욱간소화하였다. 특히타병원으로부터이송되는 STEMI 환자의경우병원간사전연락및환자도착전심전도전송을통하여경피적관상동맥중재술결정시간을단축하고내원이후 재관류까지소요되는시간을최소화하고자하였다. 저자들은 STEMI 환자에대한병원전및병원내심전도정보전달체계를구축하고개선된진료체계가치료지침에서요구하는치료시간단축에주는효과를분석하고자하였다. 대상과방법 1. 연구대상본연구는 2006년 1월부터2009년 2월까지, 800병상규모의대학병원응급실에내원한흉통환자들중초기심전도상 STEMI으로진단된환자를대상으로하였다. 프로토콜이적용되기이전, 2006년 1월에서 12월까지의자료는후향적으로의무기록을조사하여분석하였다. 프로토콜적용이후내원한 164명의환자중 10명은응급실에서심정지가발생한이후사망하여혈관조영술을시행할수없었다. 응급으로경피적관상동맥중재술을시행받은 154 명의환자들중관상동맥의유의한협착소견이없었던 12 명을제외한 142명을대상으로전향적인연구를수행하였다 (Fig. 1). Fig. 1. Study population. STEMI: ST elevation myocardial infarction, ED: emergency department, PCI: percutaneous coronary intervention

최일국외 : 심전도정보전달체계구축이 ST 분절상승심근경색환자의재관류치료시간단축에미치는효과 / 593 2. 연구프로토콜 STEMI는적어도 2개이상의연속된유도 (leads) 에서 1 mm 이상의 ST 분절상승이있는급성관상동맥증후군으로정의하였다. 본연구에서구축한병원전및병원내심전도정보전달체계는다음의프로토콜을따른다. 응급실에흉통을호소하며직접내원한환자의경우별도의지시없이도응급구조사가심전도검사를시행하도록하였고, 타병원에서전원연락을받은경우기본환자정보외에팩스전송 (facsimile, fax) 을통한심전도전송을요청하였다. 이러한경로로얻어진심전도는당직응급의학과의료진이판독한후 STEMI이라면직접심장내과전문의에게연락하여중재술팀을활성화시키도록치료방침을확정하였다. 타병원으로부터의전원의경우환자의도착전에심전도해석이이루어졌다면본원도착유무와상관없이응급의학과의료진이중재술팀을활성화시킬수있도록하였다. 1) 기초자료수집연구대상환자들의성별, 연령, 응급실방문시간및방문경로, 병원전심전도전송유무, Creatinine Kinase MB fraction (CK-MB) 과 troponin-i( 초기값과최대값 ) 의검사결과, 병원내사망률등에대한정보를수집하였다. 응급실내원시간은오전 8시부터오후 6시까지를근무시간으로, 오후 6시에서다음날오전8시까지를근무외시간으로정의하였으며, 방문경로는직접방문한경우와타병원을경유하여전원된경우로분류하였다. 2) 내원에서재관류까지의시간분절정의재관류가이루어지기까지의시간분절은크게 4단계로분류하였다. 환자가병원전심전도전송없이응급실에내원한경우, 내원이후첫번째심전도를찍기까지의시간을 T1(door-to-ECG time), 응급의학과의료진에의하여 심전도가판독되고심장내과전문의를호출하기까지의시간을 T2(ECG-to-call time), 심장내과전문의호출이후심혈관조영실에서첫번째풍선성형술이시작될때까지의시간을 T3(call-to-balloon time), 환자의응급실내원시간부터첫번째풍선성형술이시작될때까지의시간을 T4(door-to-balloon time) 로정의하였다 (Fig. 2). 환자의응급실도착전심전도가전송되었다면응급의학과의료진의판독이후직접심장내과전문의를호출하고환자내원즉시심혈관조영실로이송하여경피적관상동맥중재술을시행하였다. 3. 연구자료의분석연구대상환자의시간분절분석을통하여본연구를통하여구축한본원의 STEMI 환자의치료신속성을미국심장학회치료권고안에근거하여평가하고자하였다. 연구가진행되기이전 2006년 1월에서 12월까지본원응급실에내원한 STEMI환자의재관류시간을기준으로연구프로토콜적용의효과를분석하였다. 4. 통계학적분석각자료의통계분석을위하여 SPSS version 12.0 프로그램 (SPSS for Window release 12.0, SPSS Inc., Chiacgo, USA) 을사용하였다. 연속변수의표현에는평균과표준편차를이용하였다. 근무시간과병원전심전도전송여부에따른시간분절분석에는 Student t test를사용하였다. 95% 신뢰구간을이용하여 p값이 0.05 보다작을때통계학적인유의성을부과하였다. Fig. 2. Definition of four components of reperfusion. ED: emergency department, CL: catheterization laboratory

594 / 대한응급의학회지 : 제 22 권제 6 호 2011 1. 대상환자의특성 결 과 인 T4 는 71.2(71.2±24.3) 분이었다 (Table 2). 3. 근무시간과근무외시간에내원한환자의시간분절분석 연구프로토콜적용이후총 142명의환자가경피적관상동맥중재술을시행받았다. 대상자의평균나이는 63(63±13) 세였으며, 남성은 72% 인 102명이었다. 근무시간에내원한환자가전체의 65.5% 인 93명으로근무외시간에비하여약 2배정도많았다. 직접응급실을방문한경우 (38명, 26.8%) 보다타병원을경유하여전원된환자가 104명 (73.2%) 으로더많았다. 프로토콜적용이전인 2006년의자료와비교하였을때일반적인특성은차이가없었으나전원된환자에서의심전도전송이더욱활성화되었고 (5명(10.4%) vs 27명 (19.0%), p<0.05), 병원내사망률이감소하였다 (6명(12.5%) vs 9명 (6.3%), p<0.05)(table 1). 2. 재관류가이루어지기까지의시간분절분석 근무시간과근무외시간에내원한환자사이에내원후재관류가이루어지기까지각시간분절사이의유의한차이가없었다 (Table 3). 4. 병원전심전도전송여부에따른시간분절분석 타병원으로부터전원된환자에서병원전심전도전송이이루어진경우, 심전도전송이없었던경우보다 T2(7.3 ±3.6 vs 19.3±16.0, p<0.01), T3(43.3±14.4 vs 53.7 ±16.2, p<0.01), T4(52.3±15.4 vs 75.6±23.9, p<0.01) 시간분절모두가더짧았다 (Table 4). 5. 미국심장협회재관류치료지침에따른치료시간분석 환자가응급실에도착하여첫번째심전도를측정하기까지소요된시간인 T1은 2.4(2.4±5.5) 분이었고, 응급의학과의료진에의하여심전도가분석된후부터심장내과전문의에게연락되기까지소요된시간인 T2는 17.8(17.8± 15.4) 분이었다. 중재술팀활성화이후경피적관상동맥중재술의시행까지소요된시간인 T3는 51.8(51.8±16.4) 분이었고, 내원후재관류가이루어지기까지소요된시간 미국심장협회재관류치료지침에따르면전체 ST 분절상승심근경색환자중적어도 75% 에서내원후 90분이내에재관류가이루어지도록권고하였고저자들은이것을본연구프로토콜의목표로삼았다. 연구기간중대상환자의 79% 가내원후 90분이내에경피적관상동맥중재술을받았고재관류가이루어지기까지소요된평균시간은 Table 1. The charateristics of patiets Characteristics No (%) 2006 2007-2009 Age, mean (SD) 62 years (16.0) 63 years (17.0) <0.72 Sex, male 30 (62.5) 102 (72.0) <0.65 Visit time Regular-hours (8:00~18:00) 30 (62.5) 93 (65.5) <0.65 Off-hours (18:00~8:00) 18 (37.5) 49 (34.5) <0.51 Arrival Primary 13 (27.1) 38 (26.8) <0.55 Transfer 35 (72.9) 104 (73.2) <0.56 Pre-arrival ECG transmission Yes 5 (10.4) 27 (19.0) <0.05 No 43 (89.6) 115 (81.0) <0.05 Cardiac enzymes CK-MB, mean (SD) 52 U/L (60.0) 53 U/L (65.0) <0.65 Initial troponin I, mean (SD) 13 ng/ml (28.0) 12 ng/ml (30.0) <0.55 Maximal troponin I, mean (SD) 72 ng/ml (62.0) 70 ng/ml (65.0) <0.55 In hospital mortality 6 (12.5) 9 (6.3) <0.05 primary: by ambulance + self-transport SD: standard deviation, ECG: electrocardiogram, CK-MB: creatine kinase MB fraction p

최일국외 : 심전도정보전달체계구축이 ST 분절상승심근경색환자의재관류치료시간단축에미치는효과 / 595 61.4(61.4±14.8) 분이었다. 90분을넘긴 21% 의환자들에서도재관류가이루어지기까지의평균시간이 107.6(107.6±17.0) 분으로 120분을넘지않았다. 연구가시행되기이전인 2006년의본원자료와비교하여보아도 90분이내에재관류가이루어진환자군에서재관류시간이단축된것을확인할수있었다 (89.2±12.4분 vs 61.4±14.8 분, p<0.05)(table 5). 고 본연구를위하여 STEMI 환자의재관류시간단축을위 찰 Table 2. Time intervals and timelines of reperfusion Time, min (SD) T1 02.4 (01.5) T2 17.8 (15.4) T3 51.8 (16.4) T4 71.2 (24.3) SD: standard deviation, T1: Door-to-ECG time, T2: ECG-tocall time, T3: Call-to-balloon time, T4: Door-to-balloon time 한프로토콜을정비하고적용한결과미국심장협회치료지침에서요구하는치료목표를달성할수있었다. McNamara 등 12) 은내원후 90분이내에재관류가시행되었을때에병원내사망률은 3.0% 였으나 91분에서 150 분, 150분이상으로재관류시간이지연될때마다사망률은각각 4.2% 에서 7.4% 로비례하여증가한다고보고하였다. De Luca 등 13) 은경피적관상동맥중재술을시행받은환자의재관류시간이 30분씩지연될때마다 1년사망률의상대위험도가 7.5% 씩증가된다고하였다. ST 분절상승심근경색환자에서내원후재관류가이루어지기까지소요되는시간을최소화하기위한여러가지시도들을보고한다수의연구들이있다 11,14,15). Bradley 등 16) 은내원후재관류가이루어지기까지소요되는시간을최소화시키기위한과정으로첫째, 현장에출동한응급구조사에의해병원전 STEMI 진단, 둘째, 심장내과의료진보다응급실의료진에의하여관상동맥중재술팀조기활성화, 셋째, 응급진료부서, 응급실직원, 응급실의료진과심장내과의료진, 관상동맥중재술팀, 교환원과호출업무, 정보기술부서사이의협조문화구축및재정, 인적자원과관련한행정부서의혁신이필요하다고하였다. 다른연구에의하면심장내과의료진보다는응급실의료진에의한관상 Table 3. Time intervals and timelines of reperfusion according to duty times Regular-hours, min (SD) Off-hours, min (SD) p-value T1 02.3 (01.5) 02.6 (01.8) 0.75 T2 17.0 (14.7) 17.3 (16.8) 0.89 T3 51.3 (17.6) 52.5 (13.8) 0.68 T4 70.6 (23.8) 72.4 (25.3) 0.67 SD: standard deviation, T1: Door-to-ECG time, T2: ECG-to-call time, T3: Call-to-balloon time, T4: Door-to-balloon time Table 4. Time intervals and timelines of reperfusion according to pre-arrival ECG transmission Yes, min (SD) No, min (SD) p-value T1 01.7 (00.7) 02.5 (00.6) <0.47 T2 07.3 (03.6) 19.3 (16)0. <0.01 T3 43.3 (14.4) 53.7 (16.2) <0.01 T4 52.3 (15.4) 75.6 (23.9) <0.01 ECG: electocardiogram, SD: standard deviation, T1: Door-to-ECG time, T2: ECG-to-call time, T3: Call-to-balloon time, T4: Door-to-balloon time Table 5. Door-to-balloon times analyzed by the recommendation of ACC/AHA guidelines ACC/AHA guidelines Patients, N (%) Door-to-balloon time, min (SD) 2006 2007-2009 2006 2007-2009 90 min 33 (68.7) 112 (079) 089.2 (12.4) 061.4 (14.8) <0.05 > 90 min 15 (31.3) 030 (021) 118.2 (15.1) 107.6 (17.0) <0.06 Total 48 (100). 142 (100) 095.1 (23.1) 071.2 (24.3) <0.05 ACC/AHA: American College of Cardiology/American Heart Association, SD: standard deviation p

596 / 대한응급의학회지 : 제 22 권제 6 호 2011 동맥중재술팀활성화, 병원도착전심전도의효율적인사용, 그리고치료를위하여수행된의료행위에대한정보감시및되먹임을강력한전략으로보았다 17). 또한관상동맥중재술팀을활성화시키는단일연락체제 (single-call system) 구축, 호출후관상동맥중재술팀이 20 30분이내에가용될수있도록함, 그리고내원후재관류가이루어지기까지의시간을단축시키려는의욕을불러일으킬수있는문화와병원내경영을담당하는관리조직과의유기적인관계가형성되어있다면보다효율적인치료성과를얻을수있을것이라고하였다 18). Nissen 등 19) 도90분미만의재관류시간을지켜낸성공적인병원에서는 STEMI 환자가응급실에도착하면응급실당직의료진이당직심장내과전문의에게전화한통을함으로써직접관상동맥중재술팀을활성화시킬수있는잘짜인진료체계가구축되어있고, 활성화후 20 30분이내에관상동맥중재술팀이도착하게되며, 몇몇병원에서는병원간심전도전송을통해관상동맥중재술팀이활성화된다고하였다. Le May 등 20) 은도시권에서심전도판독훈련을받은응급구조사에의한심전도검사및판독을통해직접중재가가능한병원으로이송되는경우와타병원응급실에환자가도착하여중재시술이가능한병원으로이송되는경우의재관류시간을비교하였을때응급구조사의판단에의하여직접이송된경우재관류시간 90분이내의목표를보다빈번하게달성하였다고보고했다. 곽등 14) 은응급실의사와심장내과전문의사이의직접적인소통을기반으로하는프로토콜을개발하여 50% 의환자에서 90분이내의 door-to-balloon time을달성하였다고보고하였다. 본연구에서구축한 STEMI 환자의치료프로토콜역시전술한여러가지보고들에기초한것이다. 응급실의료진과심장내과의료진사이의직접적인소통을기반으로하여프로토콜을개발하였으며인턴이나내과전공의를의사결정과정에서배제시키고관상동맥중재술을실질적으로시행할수있는의료진을조기에활성화시킬수있도록의사결정과정을더욱간소화하였다. 연구기간동안전체 STEMI 환자의 79% 에서내원후 90분이내에재관류가이루어졌으며그평균시간은 61.4분으로본원의이전재관류시간 (89.2±12.4분) 을크게단축하였다. 이러한결과를얻을수있었던근거는환자의심전도정보를최대한빠른시간에중재술을담당하는심장내과전문의와중재술팀에게전달하고자하였던병원전및병원내심전도정보전달체계가효율적으로작동하였다는의미로해석될수있겠다. 병원전단계, 특히타병원에서 1차진료를마친후내원한환자에서병원전심전도전송이이루어졌을때심전도정보가중재술팀에전달되고의료진이활성화되는시간을포함한재관류시간이유의하게감소한것은의미가있다 [T2(7.3±3.6 vs 19.3±16.0, p<0.01), T3(43.3±14.4 vs 53.7±16.2, p<0.01), T4(52.3± 15.4 vs 75.6±23.9, p<0.01)]. 만약치료체계구축과정에서병원내치료과정의개선을통하여 ST 분절상승심근경색환자의재관류시간을유의하게감소시키지못한경우중요한개선요소로고려할수있겠다. 병원내단계에서는첫째, 흉통환자가응급실에도착하면즉시응급의학과의료진이최초진료를개시하며, 둘째, 심전도검사및판독후근무시간과근무외시간의구분없이직접중재술을담당하는심장내과전문의와연락하여관상동맥중재술팀을활성화시키고, 셋째, 재관류시간을최소화하고자하는응급의학과와심장내과와의강력한공감대형성및행정부서의지원이적절히이루어졌기때문으로판단된다. 심장내과와의적극적인공조는근무시간과근무외시간을나누어분석한시간분절이차이가없었다는결과로증명된다. 본연구에서는재관류시간을평균과표준편차로제시하였다. 중앙값을구하여보고한대다수의국내외논문들과는달리, 평균값이치료지침의목표를달성하였다는것은치료프로토콜이효율적으로수행되었다는증거가될수있겠다. 저자들의연구에는몇가지제한점이있다. 첫째, STEMI 환자에대한병원전및병원내심전도정보전달체계구축을전후로한대조군을설정하고재관류시간의단순비교외에자세한임상요소들을분석하지않았다. 그러나 STEMI 환자에대해서는국제적으로공인된치료지침이이미존재하고치료목표가명확하게제시되어있으므로, 새로운진료체계구축이후시간분절을분석하는것으로도구축된체계가치료목표의달성에미치는효과를알수있다. 둘째, 심전도전송의유무에따른환자군의구별이연구설계에따른구분이아닌임의로이루어졌다. 연구프로토콜에따라전원요청을받았을경우적극적으로병원전심전도전송을요청하였으나모든환자의정보를받을수없었던한계가분명히있다. 따라서사전에심전도정보가전달된환자에서보이는재관류시간의단축이연구자가통재할수없는요소들의영향을받았을가능성이있다. 그러나시간분절의분석결과를보면심전도정보를미리전송받은경우응급의학과의료진뿐만아니라중재술팀의반응역시사전정보가없었던경우보다신속하였다는것을알수있다. 따라서재관류시간의단축에영향을미치는병원내반응속도를파악하는의미로이항목을이해한다면혼란을줄수있는요소들에대한해석상의오류를최소화할수있을것으로판단된다. 셋째, 시간분절이목표를이루지못한경우에대한심층적인분석이이루어지지못하였다는점, 넷째, 장기간치료체계운영을통한치료성과의비교와질관리방안이제시되지못했다는점이다. 구축된심전도정보전달체계가연구기간이후에도지속될수있다는보장은당연히할수없을것이다. 지속적인질관리활동과체계개선활동의효과는이후의추가연구과제로설정할수있겠다. 다섯째, 일개대학병원의분석

최일국외 : 심전도정보전달체계구축이 ST 분절상승심근경색환자의재관류치료시간단축에미치는효과 / 597 결과로일반화시키기에는한계가있다. 그러나병원전및병원내심전도정보전달체계개선을통한국제치료지침의달성이명확하고관련진료과와의협조와치료과정의단순화, 병원전심전도획득등의쉽게적용가능한진료수단을통하여의미있는재관류시간의감소를유도할수있었다는점등은본연구와진료프로토콜이제시할수있는의의라고분석할수있다. 결 STEMI에서재관류치료시간을단축하기위해서는, 병원간이송환자의경우심전도정보를미리전송하고파악하는병원전단계에서와환자가응급실에도착한이후응급의학과의료진이중재술을담당하는심장내과의료진과근무시간, 근무외시간의구분없이직접연락할수있는병원내단계에서의심전도정보전달체계를구축하는것이효과적인것으로판단된다. 론 참고문헌 01. Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: executive summary: a report of the ACC/AHA Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines on the Management of Patients with Acute Myocardial Infarction). Circulation 2004;110:588-636. 02. available at: http:/www.kostat.go.kr/. Accessed March 31, 2009. 03. Keeley EC, Hillis LD. Primary PCI for myocardial infarction with ST-segment elevation. N Engl J Med 2007;356:47-54. 04. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet 2003;361:13-20. 05. Andersen HR, Nielsen TT, Rasmussen K, Thuesen L, Kelbaek H, Thayssen P, et al. A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. N Engl J Med 2003;349:733-42. 06. Smith SC Jr, Feldman TE, Hirshfeld JW Jr, Jacobs AK, Kern MJ, King SB 3rd, et al. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention?summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). J Am Coll Cardiol 2006;47:216-35. 07. Ryan TJ, Anderson JL, Antman EM, Braniff BA, Brooks NH, Califf RM, et al. ACC/AHA guidelines for the management of patients with acute myocardial infarction: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). J Am Coll Cardiol 1996;28:1328-428. 08. Brodie BR, Stone GW, Cox DA, Stuckey TD, Turco M, Tcheng JE, et al. Impact of treatment delays on outcomes of primary percutaneous coronary intervention for acute myocardial infarction: analysis from the CADILLAC trial. Am Heart J 2006;151:1231-8. 09. Rathore SS, Curtis JP, Chen J, Wang Y, Nallamothu BK, Epstein AJ, et al. Association of door-to-balloon time and mortality in patients admitted to hospital with ST elevation myocardial infarction: national cohort study; National Cardiovascular Data Registry. BMJ 2009;338:1807-14. 10. Nallamothu BK, Bates ER, Herrin J, Wang Y, Bradley EH, Krumholz HM, et al. Times to treatment in transfer patients undergoing primary percutaneous coronary intervention in the United States: National Registry of Myocardial Infarction (NRMI)-3/4 analysis. Circulation 2005;111:761-7. 11. Bradley EH, Herrin J, Wang Y, Barton BA, Webster TR, Mattera JA, et al. Strategies for reducing the door-to-balloon time in acute myocardial infarction. N Engl J Med 2006;355:2308-20. 12. McNamara RL, Wang Y, Herrin J, Curtis JP, Bradley EH, Magid DJ, et al. Effect of door-to-balloon time on mortality in patients with ST-segment elevation myocardial infarction. J Am Coll Cardiol 2006;47:2180-6. 13. De Luca G, Suryapranata H, Ottervanger JP, Antman EM. Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts. Circulation 2004;109:1223-5. 14. Kwak MJ, Kim K, Rhee JE, Shin JH, Suh GJ, Jo YS, et al. The effect of direct communication between emergency physicians and interventional cardiologists on door to balloon times in STEMI. J Korean Med Sci 2008;23:706-10. 15. Singer AJ, Shembekar A, Visram F, Schiller J, Russo V, Lawson W, et al. Emergency department activation of an interventional cardiology team reduces door-to-balloon times in ST-segment-elevation myocardial infarction. Ann Emerg Med 2007;50:538-44. 16. Bradley EH, Roumanis SA, Mattera JA, Radford MJ, McNamara RL, Barton B, et al. How do the fastest hospitals do it? Reducing door-to-balloon times to meet quality guidelines for patients with STEMI. Circulation 2004; 109:231-84. 17. Bradley EH, Curry LA, Webster TR, Mattera JA,

598 / 대한응급의학회지 : 제 22 권제 6 호 2011 Roumanis SA, Radford MJ, et al. Achieving rapid door-toballoon times: how top hospitals improve complex clinical systems. Circulation 2006;113:1079-85. 18. Bradley EH, Nallamothu BK, Curtis JP, Webster TR, Magid DJ, Granger CB, et al. Summary of evidence regarding hospital strategies to reduce door-to-balloon times for patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. Crit Pathw Cardiol 2007;6:91-7. 19. Nissen SE, Brush JE Jr, Krumholz HM. President s page: GAP-D2B: an alliance for quality. J Am Coll Cardiol 2006;48:1911-2. 20. Le May MR, So DY, Dionne R, Glover CA, Froeschl MP, Wells GA, et al. A citywide protocol for primary PCI in ST-segment elevation myocardial infarction. N Engl J Med 2008;358:231-40.